Medical Treatment of HIV-Infected Prisoners

Prisons and jails, designed to confine and punish people (many of whom are poor and lack influential outside advocates), frequently fail to provide the level of health services required by patients with HIV. As with other chronic illnesses, HIV requires health services that are expensive in terms of staff effort and expertise, laboratory testing, and medication. Prisons often have escaped outside attention to serious failures of care. HIV has placed an enormous fiscal burden on prisons, which already are stressed financially. The cost of HIV care in the 21st century in prisons now is rivaled by the cost and controversies surrounding management of hepatitis C, which affects up to 40% of prison inmates, and by the cost of psychotropic agents for the large number of individuals with mental illness who are imprisoned in the United States.

Prisons increasingly are recognizing the need for consultation and treatment of HIV by medical specialists, and several states provide care in conjunction with outside university-based clinic systems. Participation by HIV specialists is by no means the rule, however.(46) Treatment with potent antiretroviral therapy is the standard of care for HIV and AIDS in prisons, as in the community at large. A survey of treatment regimens of the 3,563 prisoners supplied through Stadtlander Pharmacy's Corrections Division in February 1999 found that 45% were receiving drug regimens recommended by 1998 U.S. Department of Health and Human Services guidelines. Seven percent were on regimens categorized as "alternative," 28% "not generally recommended," 8% "not recommended," and 12% were reported as "unclassified."(47)

Often, prison conditions undermine the consistent dosing schedules essential to the long-term effectiveness of antiretroviral therapy. Gaps in treatment occur due to transfers of inmates among correctional institutions. Confiscation of all medications from prisoners is also a common practice of prison staff in the course of searches for contraband. Court appearances, transfers among facilities, punitive detentions, and release from custody are all part of the prisoner's life, and provisions must be made to continue therapy through these events without interruption.

In many prisons, antiretroviral therapy is administered under direct observation to prisoners. Observers have reported that adherence to antiretroviral therapy among prisoners apparently has been good. At Rikers Island in New York City, patients' CD4 counts rose in a pattern almost identical to that found in clinical trials.(48) Among 170 prison patients in Wisconsin who self-administered medications, improvements in CD4 and viral measures were comparable with those found in community patients.(49) A 1996 survey of 205 HIV-infected prisoners eligible for potent antiretroviral therapy that found an acceptance rate of 80% and an adherence rate of 84% also found that adherence was 82% in those who received directly observed therapy, and 85% in those who self-administered medications.(50)